A Unique Case of Bilateral Valsalva Retinopathy

A 45-year-old man presented to the eye clinic with complaints of diminished bilateral central vision for four days. He had constipation and bleeding during defecation over the past five months. He experienced severe straining accompanied by a particularly heavy episode of bleeding that occurred five days ago. Thereafter, a surgeon diagnosed an anal fissure that was treated with 2% topical glyceryl trinitrate ointment. Visual acuity in both eyes was 20/200, and the examination of the anterior segment was normal. Retinal examination with an indirect ophthalmoscope revealed multiple hemorrhages in all quadrants of the retina (Figures 1(A), right eye; 1(B), left eye). The fovea in both eyes was obscured by hemorrhages that was responsible for the mechanical obstruction of the central vision (arrows). Hemorrhages were noted at the center of the macula as well (arrows). These hemorrhages beneath the internal limiting membrane (ILM) were confirmed with optical coherence tomography (OCT), obliterating the foveal dip (arrowheads). A diagnosis of Valsalva retinopathy was made. Hematological investigations showed a hemoglobin level of 7 g/dl (normal range: 13.5 to 17.5 g/dl) and a platelet count of 140,000 (normal range: 150,000 to 450,000). The patient was asked to continue the treatment with his surgeon and was reviewed regularly at the eye clinic. The treatment for the anal fissure was successful, and he was relieved of constipation in one month. Three months later, visual acuity in both eyes improved to 20/20. Retinal examination showed a complete resolution of hemorrhages. Hematological evaluation revealed that the hemoglobin level was 13.8 g/dl and the platelet count was 270,000.